As Medicaid faces another set of policy shifts, this episode provides a look-back on the many twists and turns Medicaid has faced throughout the years. Jay Rosen, president and chairman of HMA, reflects on his work with states and health plans over the past four decades in their efforts to deliver services to vulnerable populations amidst shifting federal and state priorities, innovative delivery and payment models, and increased private sector involvement. With a sharp focus on policy, equity, and system transformation, Jay offers strategic insights for leaders across healthcare, government, and investment sectors.
1306 Results found.
Disaggregating Managed Care Payments Provides Opportunities for New Insights into Medicaid Spending for Critical Populations
HMA focused this paper on how states disperse Medicaid funds to certain subpopulations within the program’s categorical eligibility infrastructure. A previous companion paper centered on increasing our understanding of Medicaid managed care spending by provider, offering more detail on the relative order of magnitude of the amounts spent on inpatient and outpatient hospital care, professional services, long-term care, pharmacy, and other health services.
As the latest national Medicaid managed care enrollment data show 75% of Medicaid beneficiaries were enrolled in comprehensive managed care organizations (MCOs), these two foundational papers illustrate the importance of developing a sound methodology to reliably estimate costs associated with MCOS. These papers, which are the first to present findings related to the development of the MCO methodologies, help lay the foundation for further work that will enable us to answer relevant questions, including:
- How much do we spend on Medicaid patients with chronic conditions like asthma, diabetes, and hypertension?
- How much do we spend on Medicaid patients receiving long-term services and supports (LTSS) and what is the unmet need?
- How is Medicaid funding spent on childbirth and a child’s first year of life?
- What are the opportunities to be more efficient and effective with Medicaid resources?
RADV Just Shifted Again: What CMS’s Latest Changes Mean for Medicare Advantage Plans
We recently sat down with Medicare experts from HMA and Wakely to break down the most important and most pressing developments shaping the future of Medicare Advantage, including the latest updates from CMS on Risk Adjustment Data Validation (RADV) audits, specifically the two major announcements released on May 21st and May 30th that are sending waves through the payer and provider communities alike.
On May 21st, CMS issued new guidance related to extrapolation and how sampling methodology and medical record review standards will evolve under the updated RADV Final Rule.
Then, just nine days later, on May 30th, CMS released additional operational instructions that may tighten reporting windows, add new thresholds for error rate evaluation, and expand expectations around provider documentation compliance—particularly for retrospective reviews and risk adjustment data sourcing.
To help unpack this fast-moving landscape, we’ve spoken with our Medicare experts, Tony Pistilli, Ryan McEntee and David Nater, each bringing a unique lens to the RADV conversation.
What was your first thought when you read CMS’s latest RADV update last week?
Tony – My main takeaway was that CMS was really upping the game in terms of what payers need to do to not only do the appropriate measures to optimize their risk scores but then audit claims that are coming in from providers. So this isn’t just a matter of ensuring that risk score optimization strategies are appropriate, not overstepping, but also adding a new administrative task of auditing claims that you’re getting from providers that may have errors in them.
Can you quickly summarize what CMS actually changed in this latest announcement, and what’s most significant about it compared to the previous announcement in November last year and previous RADV audits?
Ryan – The core of these changes, prior to the old way of doing RADV is, of course the extrapolation methodology that CMS will be introducing, as well as the elimination of the fee-for-service adjuster, which is going to be huge. Then we can move on to that with the announcement of enhancements of staffing and technology.
It’s going to be very interesting how CMS looks to utilize that. As well as every single contract being audited that is eligible are probably the focus points within this, and with CMS they give you a little, and then you have to look into it a lot, so I think there’s still a lot more to come related to these initial announcements that are coming through.
What exactly does this mean from a health plan perspective in the near term – especially for those already in the trenches of risk adjustment audits or pre-audit reviews?
David – Most financial teams use claims as forecasting and having concurrent risk adjustment processes is really the optimal approach to make sure that there are no surprises on the financial end for month end and quarterly reports. Making sure that plans are getting ahead of this cleanup now is imperative to mitigate those financial impacts, and then on a concurrent level, optimizing the operational processes ensures just better forecasting and overall better financial outcomes.
With the latest announcements regarding RADV, what are the current unknowns at play related to this new look RADV strategy?
Tony – On a technical level, the key things we don’t know are how CMS is going to sample claims – They’ve indicated that they’re going to move from random sampling to targeted sampling – and we don’t know how they’re going to extrapolate that. So, if you do a targeted sample, do you extrapolate that just to a targeted extrapolation, or do you extrapolate that to the whole plan? And that’s your range of low impact to high impact.
Similarly, we don’t know what confidence interval CMS is going to use. There’s been some indications of 99% in the past. That’s going to be very conservative, but 95 or 90% would be plausible confidence intervals as well, and that gets you to much more aggressive recovery rates. There are a few other small technical issues that I don’t think will have as big of an impact, but those are the three ones that we’re really looking to CMS to figure out.
What’s the one thing you think plans need to prioritize immediately in light of this update – and what’s the trap they need to avoid?
Ryan – I think plans need to very quickly understand their exposure. One of the ways to do that—and one of the ways we are engaging our clients—is to run analytics looking at these high-risk codes. There are also certain indicators you can look at to see what needs to be reviewed and what has high error rates, based on previous OIGYG and CMS audits. From there, you need to get a quick plan in place to document and assess whether or not those codes are relevant. If they are not, submit them before the aggressive timeline CMS has put in place.
As I mentioned, there are less than two weeks to submit deletes for 2019 dates of service, and every 7 days after that thereafter for each payment year. So, the time to act is now. You need to quickly understand where your risk is and take action. And if you don’t have those capabilities, engage with strong consulting groups or partners who can support you through this.
What closing thoughts or takeaways would you like to share?
Ryan – If I put myself on the plan side, I see both a short-term, immediate plan and a long-term sustainability plan.
That short-term immediate plan is action to act NOW. Whether that is engaging with a partner, or engaging in your internal team, you need to be able to highlight where your risk areas are. Take action on this prior to CMS coming in and acting for you. What’s just as important is setting up a long-term roadmap to be able to mitigate this risk going forward.
To look at it concurrently, do you have the right analytics in place? Do you have the correct staffing in place to be able to look at these risk codes coming in? Assess them and send the necessary deletes coupled with closing the loop related to feedback. Are you pushing that information and education back to your physician groups? Because they’re the most important part to this. You need to be able to educate, communicate and meet with your providers to explain how important the act of documentation and coding is and have this at the forefront of every one of your initiatives and incentive programs going forward in value-based care.
David – HMA and Wakely are well-positioned to help in both the short-term and the long-term approach, and ideally both. Organizations need to act quickly and align their steady-state processes to ensure that they’re managing both the exposure at the health plan level and with the providers, especially those in risk-based arrangements.
Tony – Plans need to be thinking of the RADV risk here, apart from the risk that they might see from chart reviews and other add activity. You may be a plan that’s relatively unaggressive in chart reviews and adds that think “we’re not risk here”, but CMS has now assigned you risk for all the claims that providers are submitting, and you need to be ensuring that those are correct as well.
There’s a wholly separate administrative task here that plans have now assumed responsibility for, and your revenue is just as at risk for not doing the RADV as it is for being inappropriate in your chart reviews and adds and whatnot. So, you really want to be thinking of this as two separate things and acting from both fronts.
Check out our full conversation.
Building Sustainable Health Systems
HMA Spotlight
Building Sustainable Health Systems
Today’s healthcare leaders are navigating an era of accelerated disruption. Traditional hospital models are under intense pressure from rising costs, workforce shortages, changing reimbursement landscapes, and shifting community expectations. Hospitals and health systems are increasingly challenged by issues that affect multiple areas of the business from strategy to fiscal management to clinical operations.
Financials & Revenue
Workforce
Improving Health Outcomes
Strategic Partnerships
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OUR COMMITMENT
We empower hospitals by guiding transformational decisions — protecting legacy, stabilizing operations, and building the future of healthcare, one courageous step at a time. Our HMA Delivery Systems team works with hospitals, health systems, federally qualified health centers (FQHCs) and associations to support their strategy, clinical services, operations, finance, and value-based care needs. Let us know how we can help your organization.
Five Critical Priorities for Transformation
Financial Reinvention and New Revenue Models
Optimizing operational efficiencies, increasing price transparency, and diversifying revenue through innovations like hospital-at-home.
We offer board- and CEO-level financial, operational, and strategic assessments and tailored scenario planning to evaluate service realignment, restructuring, and sustainable growth.
Workforce Resilience and Sustainability
Investing in staff retention, interdisciplinary team redesign, leadership development, and pipeline programs to stabilize care delivery and safeguard institutional knowledge.
We support clients with strategic workforce planning, interdisciplinary team optimization, and leadership development frameworks to future-proof talent pipelines.
Expanding Access and Improving Health Outcomes
Advancing accessible, high-quality care and strengthening community loyalty.
We guide the development of community health investment strategies, trust-building frameworks, and initiatives to foster patient and stakeholder loyalty.
Strategic Partnerships and Ecosystem Building
Building alliances across systems, payers, technology firms, and community organizations is essential to expanding reach, managing risk, and accelerating innovation.
We bring expertise in strategic partnership development, merger and affiliation exploration, and collaborative ecosystem strategies.
Technology and Digital Innovation
Deploying technology and AI automation to streamline workflows, enhance patient experience, and lower costs is now a competitive imperative.
We partner with hospitals to develop tailored technology enablement roadmaps—integrating digital solutions aligned with operational goals and future-state visions.
Who We Help
We offer a full suite of professional health and human services consulting services to clients serving hospitals and health systems, such as:
Critical access and PPS hospitals
FQHCs, rural health clinics, & provider practice groups
Health plans
National, regional and statewide associations
Federal, state, & local governments
Tribal nations & tribal health organizations
Community based organizations
Foundations
Contact Our Experts:
Warren J. Brodine
Managing Director, Finance and Operations
Warren Brodine partners with communities, federally qualified health centers (FQHCs), and payors to deliver optimal patient and community outcomes, supporting … Read more
CSR Funding, Budget Debates, and the Future of Marketplace Affordability
In May 2025, the US House of Representatives passed a budget bill that includes funding for cost-sharing reduction (CSR) payments, marking a potential end to the “silver loading” practice that has shaped pricing in the Affordable Care Act (ACA) Marketplace pricing since 2017. The US Senate is now considering this legislation as part of a broader budget reconciliation package that includes major Medicaid reforms, such as new work requirements and changes to eligibility and financing rules.
This evolving policy landscape has significant implications for states, payers, providers, and consumers. Wakely, an HMA Company, recently published Implications of Ending Silver-Loading on the Individual Market, which outlines how reinstating CSR payments could reshape ACA marketplace plan pricing, enrollment patterns, and federal subsidy flows. It also highlights the operational and financial risks stakeholders must prepare for in 2026.
Broad Loading and Silver Loading
Because CSR loading increases premium costs on silver plans that determine subsidies, they also increase federal payments for premium tax credit (PTC) subsidies. Guidance from the US Department of Health and Human Services on silver plan pricing has evolved over time. Three types of CSR loading are occurring in ACA markets, specifically:
- Broad loading: Increasing premiums for all metal level qualified health plans (QHPs) in the individual market to collect enough revenue to offset the CSR costs of the silver plan variants enrollees
- Two means of silver loading:
- Increasing premiums for only silver QHPs in the individual market to collect enough revenue to offset the CSR costs of the silver plan variant enrollees
- Raising premiums, functionally, for only on-exchange silver QHPs
As discussed in the Wakely paper, the impact of silver loading is that the federal government is likely paying out more in additional PTC subsidies than would be paid if CSR payments were fully funded. On Friday, May 2, 2025, the Centers for Medicare & Medicaid Services (CMS) released guidance related to silver loading and CSR payments for 2026 rate filings. This action was urgently needed, especially for states with May filing deadlines.
What’s at Stake
If Congress does appropriate funding for CSR payments, some issuers will be reimbursed for the difference in cost sharing between standard and CSR-enhanced silver plans. Issuers that cover nonemergency pregnancy termination services, would be ineligible for CSR payments; however, as the Wakely paper indicates, these payments would not cover the additional utilization driven by richer benefits. For example, it is anticipated that a member in a 94 percent actuarial value CSR plan will use more services (i.e., four primary care visits versus three in a standard plan), but reimbursement would only reflect the cost-sharing difference—not the increased volume of care.
States like Georgia and New Mexico, which mandate silver loading, could see significant shifts in premium relativities and enrollment behavior. Wakely’s modeling suggests that changes in CSR policy—especially if paired with the expiration of enhanced premium subsidies at the end of 2025—could lead to higher net premiums, reduced enrollment, and a deterioration in risk pool morbidity.
What to Watch
The Senate’s deliberations will determine whether CSR funding is restored and could have significant implications on whether enhanced premium subsidies are extended beyond 2025. These decisions will directly affect the following:
- 2026 rate filings and benefit designs
- Marketplace affordability and enrollment stability
- State reinsurance funding and 1332 waiver dynamics
- Consumer costs and plan switching behavior
Wakely’s analysis also cautions that if CSR funding is restored without accounting for induced utilization, issuers may still need to price for higher service use—potentially leading to premium volatility. In addition, if broad loading is mandated instead of silver loading, it could raise premiums across all metal tiers and reduce the value of premium tax credits for many enrollees.
Key Considerations for Stakeholders
- States should assess how CSR policy changes affect reinsurance programs, waiver funding, and Medicaid redeterminations.
- Payers must prepare for multiple pricing scenarios and evaluate how changes in subsidy structures influence enrollment and risk adjustment, 1332 reinsurance programs, and overall market risk.
- Providers should anticipate shifts in patient mix and utilization (i.e., more uncompensated care with more uninsured patients).
- Advocates need to monitor how policy changes affect access and affordability for low-income and underserved populations.
These developments also create more opportunities for movement between Medicaid, Marketplace, and uninsured populations, underscoring renewed opportunity for integrated eligibility systems and coordinated outreach.
Connect with Us
Health Management Associates (HMA), experts are actively advising stakeholders on how to navigate these complex changes. Whether you’re a state policymaker, health plan executive, provider leader, or advocate, we can help you assess the impact and plan strategically.
These issues will also be explored in depth at the HMA Conference in October 2025. To discuss how these developments will affect your organization, contact our featured expert below.
How One Organization Unlocked Exceptional Financial Gains Through Revenue Cycle Optimization
A recent case study highlighted how Health Management Associates (HMA) worked with a medical supply firm to identify gaps in their revenue cycle, and by working with us have seen improvements in denial rates and reimbursement. Advanced Diabetes Supply (ADS)/ US Medical Supply (USMed) came to HMA for help with its revenue cycle goals. What began as a revenue cycle gap assessment at one ADS office in California was expanded to be repeated for the Florida office. As a result, HMA helped ADS produce 12% YoY increase in cash collections, resulting in more than $38 million in additional revenue, and a $16 million reduction in outstanding A/R within six months.
A leading provider of diabetes supplies, ADS faced challenges in optimizing their revenue cycle processes. By partnering with HMA, they embarked on a transformative journey that resulted in streamlined operations and improved financial performance. The case study highlights the key strategies implemented by ADS and HMA, including the adoption of advanced technologies, process re-engineering, and staff training. These initiatives not only addressed existing inefficiencies but also paved the way for future growth and innovation.
Organizations need efficient revenue cycle management to ensure sustainability and growth in the constantly changing and competitive healthcare landscape. As healthcare reimbursement can involve many complex processes, it creates opportunities for gaps and process breakdowns. HMA helps organizations implement the processes, training, and technology necessary to close process gaps, improve cash flow, determine root causes for gaps, and reduce denials.
HMA experts have decades of experience in every facet of the revenue cycle. They come from all sides of the healthcare industry, including providers, payers, managed care organizations, and more.
Delve deeper into this inspiring success story by downloading the full case study and watching the accompanying video featuring a conversation with Melanie Montero, SVP at Advanced Diabetes Supply.
Evolving Medicaid Work Requirement Policies: Essential State Actions to Prepare
On May 22, 2025, the US House of Representatives advanced a comprehensive legislative package that includes expansive changes to healthcare spending and tax policies. The One Big Beautiful Bill Act, H.R. 1, will be subject to further revision in the Senate – and potentially again in the House – before it can be sent to the president for his signature. If enacted, the legislation would have significant implications for the Medicaid program, including a nationwide work and community engagement requirement. The House-passed bill establishes a deadline of December 31, 2026, for implementation, but individual states could move earlier.
As state legislatures pass work requirement bills, governors consider executive actions, and Congress contemplates revisions to the Medicaid work mandate, vetting key implementation issues may significantly affect the direction of related policies. Even before implementation, states must test operations, enable systems, and establish connections to beneficiaries to reduce potential implementation missteps, inappropriate disenrollments, and litigation risks.
If the goal of Medicaid work requirement policies is to stimulate connections between health benefits and employment/workforce, building state and federal capacities to support these approaches is critical to effectuating that change. In the remainder of this article, Health Management Associates (HMA), experts focus on the operational dynamics that need to be discussed, tested, and built as states begin introducing work and community engagement initiatives.
Federal Policies and Early State Actions on Work Requirements
The House bill would require all states to implement work and community engagement requirements for adults without dependents for at least 80 hours per month.[1] Employment, work programs, education, or community service (or a combination of those activities) would satisfy the requirement.
The work requirements in the House-passed legislation would apply only to individuals between the ages of 19 and 64 without dependents, and the following groups are exempted:
- Women who are pregnant or entitled to postpartum medical assistance
- Members of Tribes
- Individuals who are medically frail (i.e., people who are blind, disabled, with chronic substance use disorder, has serious or complex medical conditions, or others as approved by the Secretary of the US Department of Health and Human Services)
- Parents of dependent children or family caregivers to individuals with disabilities
- Veterans
- People who are participating in a drug or alcoholic treatment and rehabilitation program
- Individuals who are incarcerated or have been released from incarceration in the past 90 days
In addition, individuals who already meet work requirements through other programs, such as Temporary Assistance for Needy Families (TANF) or the Supplemental Nutrition Assistance Program (SNAP), would be exempt. However, the House-passed version would make the eligibility verification and work requirements for SNAP more stringent and shift program costs to these states, which would affect cross-functional eligibility. The legislation also includes temporary hardship waivers for natural disasters and areas with an unemployment rate greater than 8 percent (150 percent of the national average).
Though the federal budget package has received a great deal of attention, at least 14 states already have moved forward (see Table 1) in advance of the current federal debate by passing laws and submitting work requirement demonstration requests to the Centers for Medicare & Medicaid Services (CMS).
Table 1. A Review of 2025 States’ Approaches to Work Requirements in Medicaid
| Status | State | Population Criteria | Requirements | Exemptions/ Notes | Public Comment |
| Work Requirement Request Submitted | Arizona | Ages 19−55 | 80 hours/month | Multiple exemptions; 5-year lifetime limit | Closed |
| Work Requirement Request Submitted | Arkansas | Ages 19−64; covered by a qualified health plan (QHP) | Data matching to assess whether on track/not on track | No exemptions | Closed |
| Work Requirement Amendment Request Submitted | Georgia | Ages 19−64; 0-100% FPL | 80 hours/month | Already has approval but is requesting reporting be changed from monthly to annually and adding more qualifying activities | Federal comment period open through June 1, 2025 |
| Work Requirement Request Submitted | Ohio | Ages 19−54; expansion adults | Unspecified hours | Limited list of exemptions | Closed |
| Legislation Passed | Idaho | Ages 19−64 | 20 hours/week required | Limited list of exemptions | — |
| Legislation Passed | Indiana | Ages 19−64; expansion adults | 20 hours/week required | Limited list of exemptions | — |
| Legislation Passed | Montana | Ages 19−55 | 80 hours/month required | Multiple exemptions | — |
| Ballot Initiative Passed | South Dakota | Expansion adults | — | 2024 ballot initiative asking voters for approval for state to impose work requirements for expansion adults passed | — |
| Legislation Pending | North Carolina | — | — | Pursue requirements that are CMS approvable | — |
| Work Requirement Request Draft | Iowa | Ages 19−64; expansion adults | 100 hours/month required | Limited list of exemptions Separate bill would end expansion if work requirements are withdrawn/ prohibited (80 hr./mo.) | Closed |
| Work Requirement Request Draft | Kentucky | Ages 19−60; no dependents; enrolled more than 12 months | Connected to employment resources | Multiple exemptions | State comment period open through June 12, 2025 |
| Work Requirement Request Draft | South Carolina | Ages 19−64; 67%−100% FPL | Specified activities (work specific is 80 hours/month) | Limiting participation to 11,400 individuals based upon available state funding | State comment period open through May 31, 2025 |
| Work Requirement Request Draft | Utah | Expansion adults ages 19−59 | Register for work, complete an employment training assessment and assigned job training, and apply to jobs with at least 48 employers within 3 months of enrollment | Several exemptions, largely aligned with federal SNAP exemptions | State comment period open through May 22, 2025 |
| Anticipated Waiver Request | Alabama | Non-expansion population | — | Potential to resubmit previous work requirement demonstration request | — |
Key Questions to Guide State Policy Decisions
Considerable research and findings from previous Medicaid work requirement initiatives can help prepare policymakers to implement a potential new phase of Medicaid work requirement policies. Some previous findings include the high cost of administration relative to potential savings, the importance of systems that support foundational items like logging an enrollee’s compliance activities and exemptions, as well as developing an efficient appeals process. The Medicaid and CHIP Payment and Access Commission (MACPAC), General Accounting Office, National Institutes for Health, and multiple researchers have published assessments regarding previous experiences that could prove useful in policy making.
HMA experts have experience identifying key issues and considerations, analyzing options, and implementing critical issues and for state leaders and stakeholders who will be responsible for implementing work requirements. Several of these issues are described below and in more detail in the HMA blog, Building State Capacities for Medicaid Work and Community Engagement Requirements.
- Exemptions, particularly medical frailty definitions and assessments. The federal government and states will need to identify individuals classified as “medically frail” and make them exempt from the mandates. Medically frail individuals include those with chronic, serious, or complex medical conditions. Various methods can be employed to identify these people.
- Developing and streamlining systems and processes to promote continued coverage for eligible individuals. The Medicaid unwinding from the COVID public health emergency taught policymakers lessons about the complexities of Medicaid systems, patient engagement, and reliable methods of member outreach. State Workforce Commissions and Departments of Labor are clear partners, as they manage integrated eligibility systems and data-sharing agreements across programs like SNAP and TANF, which also serve many Medicaid participants. These and other partnerships will need further exploration.
- Clinical and utilization data that promote eligibility assessment. Many, but not all, individuals with chronic diseases may be exempt from the requirements. Knowing the health status and chronic conditions of the populations affected and the conditions that qualify people for exemption are variables as implementation questions, like the definition of medically frail, are addressed.
- Anticipated need for effective Medicaid managed care engagement in work requirements/community engagement initiatives. Approximately 80 percent of Medicaid expansion enrollees are members of comprehensive managed care organizations (MCOs). States will need to review the scope of existing vendor contracts as well as determine the need for new services, roles, third-party reporting, oversight, and potential exemptions for emergencies. Work requirements can disrupt MCO risk pool stability and care coordination. MCOs have a financial incentive to drive down inappropriate disenrollments and are uniquely positioned to support state responsibilities, including maintenance of up-to-date contact information.
- Measuring impact and adapting policies as needed. Dynamic metrics that provide actionable information to federal and state policy makers will support effective oversight and monitoring.
Connect with Us
HMA helps stakeholders—including state agencies and their partners—manage the challenges of implementing new Medicaid or CHIP initiatives, with a focus on ensuring efficient integration and improvements in outcomes. Our teams are adept at developing materials for and supporting stakeholder engagement from design to implementation, which is a critical aspect for work and community engagement initiatives and other potential new eligibility and renewal requirements.
For support tracking federal and state level developments and enhancing your organization’s strategy and preparations for new Medicaid requirements, contact our featured experts below.
[1] U.S. Congress. House. One Big Beautiful Bill Act. H.R.1. 119th Cong., 1st sess. Introduced May 20, 2025.
May 28, 2025
Building State Capacities for Medicaid Work and Community Engagement Requirements
What If Mental Health Checkups Were as Normal as Mammograms?
Monica Johnson, managing director at Health Management Associates, takes us through her compelling journey from frontline caregiver to national leader in behavioral health policy. In this episode of Vital Viewpoints on Healthcare, Monica reflects on the national rollout of the 988 crisis line as one of the most transformative shifts in creating a stigma-free behavioral health system of care that meets people where they are to support whatever crisis they may face. Monica shares personal stories and strategic insights that illuminate why policymakers must ensure these systems prioritize the local needs of patients and providers. We explore the future of crisis care, the enduring need for bold federal-state collaboration, and why it’s time to normalize mental health checkups.
The Changing Behavioral Health Landscape in a Time of Fiscal Uncertainty; Learn more at HMA’s Behavioral Health Town Hall May 29
It is hard to keep abreast of the changes being made to the healthcare system at the Federal level, and how these changes will impact behavioral health (BH) services. The current reprioritization of funding by the Department of Health and Human Services (HHS) and the proposed changes in the budget bill pending in Congress will significantly reshape Medicaid and critical behavioral health programs. States and local organizations will need to sharpen their understanding of this new funding landscape, so they are able to focus on addressing critical needs for prevention and treatment of mental health and substance use disorders.
Register today – HMA’s Behavioral Health Town Hall, Thursday, May 29 at 12 p.m.
With Federal funding levels in question, States and their stakeholders need to consider how they are funding BH initiatives. We’ll address participant questions and topics we know are top of mind, for example:
What steps can states take to ensure sustainable funding for critical programs? Are states strategically utilizing their Medicaid programs to preserve BH specific program dollars for other purposes? What efficiencies and enabling technologies can organizations adopt to support their mission? How should state and local entities be thinking about the opioid settlement dollars to maximize support for services and initiatives that face uncertain future financial support?
In addition, Congress is debating changes to Medicaid eligibility and funding policies that may result in shifts in key aspects of the program. States can start planning now for changes to their processes and for outreach and education campaigns that will be essential in supporting individuals with mental health and substance use disorder diagnoses. Payers should be planning for changes in enrollment and enrollee risk profiles while providers should expect changes in their payer mix and a need for enhanced collaboration with community organizations. Are there different models that can be pursued to effectively navigate these shifts? How will all of this uncertainty affect the BH workforce? Stakeholders need to be prepared to engage in downside risk arrangements, think about their patient/consumer engagement strategies and integrating digital BH tools that are the focus of the CMS Innovation Center agenda.
You probably have questions that we didn’t even list here. Here is your chance to ask them: Join HMA on Thursday, May 29 at 12 p.m. at a dynamic and interactive Behavioral Health Town Hall where HMA experts Heidi Arthur, Rachel Bembas, Allie Franklin, Teresa Garate, Monica Johnson, and Sara Singleton will be available to answer your questions live on a wide range of critical topics, including:
- Federal policy, personnel, and funding changes;
- Emerging strategies for addressing social determinants of health, substance use disorder and crisis coordination (including 988);
- Leveraging cross-sector partnerships to build ecosystems of care across communities promoting coordination and collaboration;
- Behavioral health revenue cycle management and alternative payment models; and
- Innovations in addressing workforce shortages, integrated service delivery, digital mental health tools, and best practices for community mental health service delivery.
Whether you’re navigating regulations, searching for new funding, designing service delivery systems, or just trying to understand what happens next, this town hall is your chance to ask questions, share insights, and discuss real-world solutions with industry experts.
CMS Seeks Input on the Future of Digital Health: What the Health Technology Ecosystem RFI Means for Stakeholders
This week, in our In Focus section, health IT experts at Leavitt Partners, an HMA Company, review the recently released Request for Information (RFI) from the Centers for Medicare & Medicaid Services (CMS) and the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health (ASTP/ONC), titled Health Technology Ecosystem (CMS-0042-NC). The RFI, published May 16, 2025, signals a renewed federal focus on advancing digital health tools, improving data interoperability, and supporting patient-centered innovation.
Notably, this RFI aligns with the vision laid out in Leavitt Partners’ Kill the Clipboard policy blueprint, developed in collaboration with a broad coalition of healthcare stakeholders. The paper outlines a future in which patients and providers benefit from seamless digital experiences, real-time data exchange, and reduced administrative burden. The RFI reflects many of the same priorities—such as expanding FHIR® Application Programming Interfaces (APIs), improving provider directories, and promoting digital identity solutions—that were highlighted in the paper as essential to modernizing the healthcare system.
Why This RFI Matters
The RFI invites public input on how CMS and ASTP/ONC can strengthen the digital health ecosystem for Medicare beneficiaries. It builds on years of federal investment in interoperability. The agencies are now seeking feedback on how to reduce barriers to data access, promote innovation in digital health products, and align technology with value-based care goals.
This is a pivotal opportunity for stakeholders to shape the future of digital health policy—especially as CMS continues to explore how APIs, digital identity, and patient-facing tools can improve care delivery and outcomes.
Key Themes in the RFI
The RFI is broad in scope, but several themes stand out, including:
- Addressing Patient and Caregiver Needs: The RFI asks patients which digital tools would be most helpful to them and their caregivers in managing their health needs, navigating care, and accessing all relevant health information in one place. It asks what features are most needed, what is missing from current apps, and how CMS can support adoption, especially for Medicare beneficiaries with limited digital experience. CMS is exploring how to make more data—beyond claims and clinical data—available through APIs. It also explores the role that CMS should play in reviewing and measuring the real-world impact of these tools on outcomes and costs. They also are considering how to promote the use of secure, standardized digital identity credentials (e.g., Login.gov, ID.me) to streamline patient access. Feedback also is sought on how TEFCA, FHIR APIs, and health information exchanges (HIEs) can better support seamless data exchange.
- Provider Adoption of Digital Health Tools: CMS is exploring how to help providers, especially those in rural areas, adopt digital health tools by addressing barriers like workflow integration, data access, and interoperability. CMS is also looking to improve administrative functions like scheduling and intake through third-party apps. In addition, CMS is seeking to understand which FHIR APIs and capabilities are already being supported or utilized in provider systems. They are also interested in understanding how providers might accept standardized digital identity credentials from patients and any challenges that might inhibit its adoption. ASTP/ONC is also seeking information on revisions to the information blocking requirements.
- Engaging Payers: The RFI invites payers to share how they can support interoperability and digital innovation, including through the use of APIs, digital identity credentials, and real-time access to clinical quality data. CMS is also interested in how payers can reduce provider burden, support value-based care (VBC), and contribute to a more connected digital health infrastructure. Feedback is requested on TEFCA participation, payer-to-payer data exchange, and the potential for a nationwide provider directory.
- Advancing VBC Organizations: The RFI emphasizes the role of digital health in supporting alternative payment models (APMs) and accountable care organizations. CMS is seeking feedback on which digital capabilities are most essential for success in VBC—such as care coordination, quality measurement, and patient engagement—and how certification criteria and data standards can better align with these needs. The agencies are also exploring how to reduce complexity for APM participants while maintaining flexibility and data access.
- Enabling Technology Vendors, Data Providers, and Networks: The RFI requests feedback from developers, data aggregators, and HIEs on how to unlock innovation through better access to CMS data, improved API standards, and streamlined certification processes. The RFI asks which technical and policy changes would enable more effective digital health products, recommendations to improve interoperability across networks, and means of supporting the viability of data exchange infrastructure.
Implications for Stakeholders
This RFI is more than a technical exercise; it is a strategic signal. The Trump Administration is maintaining momentum behind VBC and digital transformation. Stakeholders should consider:
- Submitting comments to CMS by the June 16, 2025, deadline.
- Assessing internal readiness to adopt or develop digital tools that align with CMS’s vision.
- Engaging in policy discussions regarding digital identity, data standards, and patient access.
- Monitoring related RFIs, including the Food and Drug Administration RFI exploring the potential use of HL7 FHIR standards to support the submission of study data derived from real-world data sources—such as electronic health records, claims, and registries—for regulatory purposes.
Next Steps
Health Management Associates, Inc. (HMA), encourages healthcare organizations to review the RFI and consider how their experiences, innovations, and challenges can inform CMS’s next steps. This is a rare opportunity to influence the infrastructure that will shape digital healthcare for years to come.
For support in drafting comments or understanding how this RFI intersects with your organization’s strategy, contact our Leavitt Partners health IT experts below.